Dec

28

Gordon Hendrickson of Albuquerque won a long legal fight with his insurance company after it refused to cover his live-saving treatment for pancreatic cancer in Houston.

By Denise Grady, The New York Times – A glorious blend of forces came together to save Gordon Hendrickson’s life: smart doctoring, luck, kindness, and his own wisdom and abundant grit.

Only his insurance company tried to stand in the way.

Five years ago, when Mr. Hendrickson was 66, routine blood work found something amiss with his liver. One test led to another, and then to an awful diagnosis: pancreatic cancer, one of the deadliest kinds.

His doctors thought he was among the lucky few with pancreatic cancer found early enough to be cured by surgery. But they warned him not to have the surgery in his home city, Albuquerque. They said the operation he needed, a Whipple procedure, was so risky and complicated that it should be done only by a surgeon who performed it often and at a hospital with many similar cases. But neither was available locally.

Albuquerque’s population was less than half a million, and the entire state of New Mexico had fewer than two million people, not enough to give local surgeons much practice with a relatively uncommon operation.

An experienced surgeon and hospital can significantly increase the odds of survival for people with pancreatic cancer, studies have found. Lower complication rates can also minimize the cost.

Mr. Hendrickson, a retired administrator for the YMCA and the Spina Bifida Association, had taken care in choosing his internist, Dr. Kristine Bordenave. They liked and trusted each other, and one morning, Dr. Bordenave canceled her other appointments to spend hours on the phone finding a major cancer center that would quickly admit him. It turned out to be the M. D. Anderson Cancer Center in Houston.

But his insurer, the Presbyterian Health Plan, refused to pay for treatment in Houston. The company insisted that the operation be done in Albuquerque and sent him a list of five local surgeons.

He went to M. D. Anderson anyway. But because Presbyterian would not pay, the hospital required a $5,000 deposit. Mr. Hendrickson and his wife had little money and normally threw away any credit cards mailed to them. But his wife happened to have one new card that she had not gotten around to cutting up yet. They decided that this was the one time when they should not worry about money, and they used the card to pay the deposit.

“I was a person who wanted to live,” Mr. Hendrickson said, adding that he assumed it would be cheaper for the insurance company to let him die.

The surgeon at M. D. Anderson told him that without an operation he had virtually no chance of surviving, and even with an operation his chances would be slim. Despite the long odds and the high cost, insurers cover the Whipple operation in patients who are candidates for it — less than a quarter of those with pancreatic cancer — because it offers the only hope of a cure and can prolong life.

Figuring that a small chance was better than none, Mr. Hendrickson had the surgery. It went well. But he was left with more than $80,000 in medical bills, which Presbyterian Health Plan refused to pay.

Dr. Bordenave said she was appalled: “No patient fighting for their life should have to fight for their insurance too.”

Mr. Hendrickson waged a long battle with Presbyterian. “I fought with the insurance company for over a year,” he said.

After Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer. Presbyterian showed up with two lawyers, a doctor and a nurse. Dr. Bordenave and a gastroenterologist from Albuquerque testified on Mr. Hendrickson’s behalf.

Mr. Hendrickson and his wife had studied the details of their insurance policy and had also learned — with the help of M. D. Anderson — that in the previous five years, the five surgeons Presbyterian had recommended had performed a total of five Whipple operations.

A spokesman for Presbyterian said the case had led the company to allow more patients to be treated at high-volume centers if there was evidence that the results would be better.

Mr. Hendrickson said it was “tough to stand up to attorneys and doctors. I don’t know why I was able to do it. I’m stubborn, I guess. I don’t like to be told what to do. Too many people, I know, they just let it go and they die.”

In June, Mr. Hendrickson went back to M. D. Anderson for a five-year checkup with his surgeon, a visit paid for by Presbyterian.

“He told me that I was cured of pancreatic cancer,” Mr. Hendrickson said in an e-mail message. “I shouted from the rooftops.”